Ovarian cancer in elderly women

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1 Ovarian cancer Ovarian cancer in elderly women Claire FALANDRY, Michel FABBRO, Olivier GUERIN, Jean-Emmanuel KURTZ, Anne LESOIN.

2 Problem Background Population on the rise and extremely heterogeneous Delayed in diagnosis, more advanced stages, under-treated, few patients enrolled in clinical trials, few or no standard management protocols, higher toxicity of treatments, life expectancy often inaccurately estimated, insufficient weight given to geriatric parameters Question: How do you define elderly Recommendation: Age over 70 years Rationale: The age limit in most clinical trials and references is 70 years Expert opinion There are wide inter-individual variations in how people age between 70 and 75 years old

3 Geriatric screening Geriatric screening is recommended for all women aged 70 and over Suggested instrument The G8 Geriatric workup to be done if: G8 < 14 Rationale Two studies have demonstrated the value of screening tools for the identification of geriatric risk patients Repetto L. et al. J Clin Oncol 2002;20: Extermann M et al. Crit Rev Oncol Hematol 2004;49: If followed by a corrective action plan, the geriatric assessment has a positive impact on functional autonomy McCorkle R et al. J Am Geriatr Soc 2000;48: Expert opinion Level 1 Grade A

4 Vulnerability factors to be screened for What are the physiological vulnerability factors which may interact with the patient s oncological management and must therefore be assessed? > 2 Comorbidities Age > 80 Malnutrition Functional capacity: autonomy Psycho-cognitive impairment Socio-economic environment Level 3

5 Ovarian cancer Ovarian cancer surgery in elderly women

6 Principles Whatever the age of the patient, the quality of the cytoreductive surgery is a major prognostic factor Objective: R0 The impact of the surgical environment on peri-operative morbidity and mortality increases with age. Requirements: Trained surgeon Centre of excellence Scheduled surgery Nonetheless, surgery is to be advised with caution: Level 1 Grade A Age has a major impact on the peri-operative risk of morbiditymortality The probability of R0 resection decreases with age It may compromise the subsequent administration of chemotherapy

7 Pre-operative geriatric assessment The geriatric assessment can be used to predict post-operative mortality and morbidity The PACE score is the only scale to have been validated retrospectively (it combines the anaesthetic score, the geriatric assessment result, fatigue score and PS) Expert opinion These tools require validation in prospective studies

8 Before surgery Pre-operative conditioning consists of: Pre-operative geriatric assessment Pre-operative nutrition (ESPEN recommendations) Pre-operative immune-enhancing nutrition in all cases Enteral nutrition days before surgery in case of severe malnutrition Level 1 Grade A Arends, J. et al. Clinical Nutrition (2006) 25, The pre-operative assessment of the lesions is an important aid to decision-making and prognosis assessment Initial laparoscopy Expert opinion

9 Some surgical procedures are to be avoided Simple exploratory laparotomy Extensive resections Gastrointestinal stoma

10 Initial surgery or interval debulking surgery The treatment goal in elderly women is to adapt the surgery/chemotherapy sequence to the patient, avoiding both over- and under-treatment Initial chemotherapy (advanced stages) Decrease the extent of the surgery required Increase the chances of complete cytoreduction Decrease peri-operative mortality and morbidity Expert opinion In elderly women, initial chemotherapy is an appropriate alternative of achieving optimal resectability during interval debulking surgery Expert opinion

11 Medical treatment Ovarian cancer of ovarian cancer in elderly women Chemotherapy and bevacizumab

12 Chemotherapy Feasibility data (at-risk populations) Carboplatin-cyclophosphamide (FAG1) 72% Carboplatin AUC5-paclitaxel 175 mg/m² q 3w (FAG2) 68% Carboplatin AUC5 (FAG3) monotherapy 74% Weekly carboplatin AUC2-paclitaxel 60mg/m² 3wks/4 (MITO5) 88.5% In the absence of specific, validated data, these protocols are the possible therapeutic options

13 First-line treatment with bevacizumab The data available are insufficient to be used as a basis for recommendations No studies specifically focussing on elderly women 2 studies (ICON7, GOG218) do not find any differences in the activity of bevacizumab according to age (< 60, 60-70, > 70 years) The following must be evaluated: Expert opinion - comorbidities (hypertension, hypercholesterolemia), - associated risk factors (history of arterial events, gastrointestinal anastomosis).

14 Chemotherapy for recurrence No standard approach Same recommendations as for younger women depending on the general condition and wishes of the patient. The decision to administer chemotherapy depends on the length of the platinum-free interval: Platinum-sensitive disease: the risk of neurotoxicity when paclitaxel is re-introduced is higher than in young women: value of the carboplatin-caelyx combination (sub-group analysis) Early recurrence: no specific data Focus on psychological support and supportive care